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Subcutaneous narcotic infusions for cancer pain: treatment outcome and guidelines for use.
CMAJ. 1992 Mar 15; 146(6):891-7.CMAJ

Abstract

OBJECTIVE

To provide guidelines for the institution and maintenance of a continuous subcutaneous narcotic infusion program for cancer patients with chronic pain through an analysis of the narcotic requirements and treatment outcomes of patients who underwent such therapy and a comparison of the costs of two commonly used infusion systems.

DESIGN

Retrospective study.

SETTING

Tertiary care facilities and patients' homes.

PATIENTS

Of 481 patients seen in consultation for cancer pain between July 1987 and April 1990, 60 (12%) met the eligibility criteria (i.e., standard medical management had failed, and they had adequate supervision at home).

INTERVENTION

Continuous subcutaneous infusion with hydromorphone hydrochloride or morphine started on an inpatient basis and continued at home whenever possible.

OUTCOME MEASURES

Patient selectivity, narcotic dosing requirements, discharge rate, patient preference for analgesic regimen, side effects, complications and cost-effectiveness.

RESULTS

The mean initial maintenance infusion dose after dose titration was almost three times higher than the dose required before infusion (hydromorphone or equivalent 6.2 v. 2.1 mg/h). Eighteen patients died, and the remaining 42 were discharged home for a mean of 94.4 (standard deviation 128.3) days (extremes 12 and 741 days). The mean maximum infusion rate was 24.1 mg/h (extremes 0.5 and 180 mg/h). All but one of the patients preferred the infusion system to their previous oral analgesic regimen. Despite major dose escalations nausea and vomiting were well controlled in all cases. Twelve patients (20%) experienced serious systemic toxic effects or complications; six became encephalopathic, which necessitated dose reduction, five had a subcutaneous infection necessitating antibiotic treatment, and one had respiratory depression. The programmable computerized infusion pump was found to be more cost-effective than the disposable infusion device after a break-even point of 8 months.

CONCLUSIONS

Continuous subcutaneous infusion of opioid drugs with the use of a portable programmable pump is safe and effective in selected patients who have failed to respond to standard medical treatment of their cancer pain. Dose titration may require rapid dose escalation, but this is usually well tolerated. For most communities embarking on such a program a programmable infusion system will be more cost-effective than a disposable system.

Authors+Show Affiliations

Department of Clinical Neurological Sciences, University of Western Ontario, London.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

1371946

Citation

Moulin, D E., et al. "Subcutaneous Narcotic Infusions for Cancer Pain: Treatment Outcome and Guidelines for Use." CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne, vol. 146, no. 6, 1992, pp. 891-7.
Moulin DE, Johnson NG, Murray-Parsons N, et al. Subcutaneous narcotic infusions for cancer pain: treatment outcome and guidelines for use. CMAJ. 1992;146(6):891-7.
Moulin, D. E., Johnson, N. G., Murray-Parsons, N., Geoghegan, M. F., Goodwin, V. A., & Chester, M. A. (1992). Subcutaneous narcotic infusions for cancer pain: treatment outcome and guidelines for use. CMAJ : Canadian Medical Association Journal = Journal De l'Association Medicale Canadienne, 146(6), 891-7.
Moulin DE, et al. Subcutaneous Narcotic Infusions for Cancer Pain: Treatment Outcome and Guidelines for Use. CMAJ. 1992 Mar 15;146(6):891-7. PubMed PMID: 1371946.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Subcutaneous narcotic infusions for cancer pain: treatment outcome and guidelines for use. AU - Moulin,D E, AU - Johnson,N G, AU - Murray-Parsons,N, AU - Geoghegan,M F, AU - Goodwin,V A, AU - Chester,M A, PY - 1992/3/15/pubmed PY - 1992/3/15/medline PY - 1992/3/15/entrez SP - 891 EP - 7 JF - CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne JO - CMAJ VL - 146 IS - 6 N2 - OBJECTIVE: To provide guidelines for the institution and maintenance of a continuous subcutaneous narcotic infusion program for cancer patients with chronic pain through an analysis of the narcotic requirements and treatment outcomes of patients who underwent such therapy and a comparison of the costs of two commonly used infusion systems. DESIGN: Retrospective study. SETTING: Tertiary care facilities and patients' homes. PATIENTS: Of 481 patients seen in consultation for cancer pain between July 1987 and April 1990, 60 (12%) met the eligibility criteria (i.e., standard medical management had failed, and they had adequate supervision at home). INTERVENTION: Continuous subcutaneous infusion with hydromorphone hydrochloride or morphine started on an inpatient basis and continued at home whenever possible. OUTCOME MEASURES: Patient selectivity, narcotic dosing requirements, discharge rate, patient preference for analgesic regimen, side effects, complications and cost-effectiveness. RESULTS: The mean initial maintenance infusion dose after dose titration was almost three times higher than the dose required before infusion (hydromorphone or equivalent 6.2 v. 2.1 mg/h). Eighteen patients died, and the remaining 42 were discharged home for a mean of 94.4 (standard deviation 128.3) days (extremes 12 and 741 days). The mean maximum infusion rate was 24.1 mg/h (extremes 0.5 and 180 mg/h). All but one of the patients preferred the infusion system to their previous oral analgesic regimen. Despite major dose escalations nausea and vomiting were well controlled in all cases. Twelve patients (20%) experienced serious systemic toxic effects or complications; six became encephalopathic, which necessitated dose reduction, five had a subcutaneous infection necessitating antibiotic treatment, and one had respiratory depression. The programmable computerized infusion pump was found to be more cost-effective than the disposable infusion device after a break-even point of 8 months. CONCLUSIONS: Continuous subcutaneous infusion of opioid drugs with the use of a portable programmable pump is safe and effective in selected patients who have failed to respond to standard medical treatment of their cancer pain. Dose titration may require rapid dose escalation, but this is usually well tolerated. For most communities embarking on such a program a programmable infusion system will be more cost-effective than a disposable system. SN - 0820-3946 UR - https://www.unboundmedicine.com/medline/citation/1371946/Subcutaneous_narcotic_infusions_for_cancer_pain:_treatment_outcome_and_guidelines_for_use_ L2 - https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/1371946/ DB - PRIME DP - Unbound Medicine ER -